Medicaid Parity Is Key Topic CMS Official Addresses in Meeting With FPs

Performance-based Compensation Also Discussed

CMS Deputy Administrator Cindy Mann, J.D., listens carefully as family physicians and AAFP chapter leaders pepper her with questions and suggestions about how to strengthen Medicaid for patients and physicians.

Payment for physicians who care for Medicaid patients has traditionally lagged behind Medicare payment, but federal government policy in the past two years has made strides to change that.

That's according CMS Deputy Administrator Cindy Mann, J.D., who met with AAFP leaders and chapter executives here on Oct. 19 -- in advance of the opening of the 2014 Congress of Delegates -- to discuss a full agenda of issues related to the Medicaid program.

The AAFP extended the invitation to Mann expecting that family physicians would have lots of questions for the woman tasked with developing and implementing national policies that govern a number of federal programs, including Medicaid and the Children's Health Insurance Program (CHIP).

In fact, in a wide-ranging discussion, Mann addressed the progress made in implementing the Patient Protection and Affordable Care Act (ACA), the increased Medicaid payment for primary care and ongoing efforts to support physician payment reform.

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Cindy Mann, J.D., deputy administrator of CMS, said some states that initially resisted expansion of Medicaid now are in discussions with federal officials to do so.

Mann said she hopes that the increased primary care payment for Medicaid will continue beyond 2014.

Insurance enrollment rates are rising by 20 percent in states that chose to expand Medicaid.

Taking On Medicaid Expansion

Mann told her audience that, to date, 27 states and the District of Columbia had expanded their Medicaid and CHIP programs as part of ACA implementation. Many states opted to not expand Medicaid when the U.S. Supreme Court ruled that expansion was voluntary for the states, but some of those states are having second thoughts. For example, Mann said that despite some initial resistance, CMS was in discussions with officials in Utah and Indiana to expand Medicaid.

"We continue to talk with the states," Mann said. "Support for expanding Medicaid is very strong."

She reminded the audience that the federal government will pay for 100 percent of the costs of Medicaid expansion at the state level from 2014-2016. After that, federal funding will decline gradually but will not drop below 90 percent.

In states that expanded Medicaid, insurance enrollment increased by 20 percent compared with an increase of 5 percent in states that chose not to expand, according to Mann. In 2013, 17.3 percent of Americans had no insurance. The figure dropped to 13.4 percent during the second quarter of 2014.

"We're seeing a startling decline in the number of uninsured in America," she said.

Medicaid is attempting to make its payments and policies consistent with those of other payers, including Medicare and private insurers, said Mann. But she cautioned that the population covered by Medicaid differs substantially from individuals covered by these other plans both in demographic terms and in the types of care received. As a result, payment policies and coverage requirements can be difficult to align with those of other payers.

Joseph Miller, M.D., of Lexington, Neb., calls for a repository of information about how family physicians are advocating for -- and taking care of -- their patients who are covered by Medicaid so that those experiences can be shared from state to state.

"We cover more children and people with disabilities," Mann said, comparing the program with Medicare. Although she acknowledged that some overlap exists between Medicaid and Medicare, the two programs are quite different in many ways.

Mann noted that in an attempt to attract more physicians to participate in Medicaid, CMS increased Medicaid payment for specific primary care services to achieve parity with Medicare during 2013 and 2014. But the payment increase is set to expire at the end of 2014 unless Congress extends it. Mann said there is support from the Obama administration to maintain the increased payment.

"It was in the president's budget to extend it," she said. "It is a priority for us. We all wanted it to be for longer than two years."

Mann noted that even when the law's provision expires, nothing prevents states from continuing to make the increased primary care payment, and, according to a recent survey(kff.org) from the Kaiser Family Foundation, 15 states have announced they plan to do so. Another 24 states and the District of Columbia will not continue the payment when federal funding ends on Dec. 31, and 12 states remain undecided.

Although Connecticut reported a significant increase in physician participation, most states are still evaluating whether the increased payment led to higher Medicaid participation rates by physicians.

Mann Fields Attendees' Queries

During a question-and-answer session that followed Mann's remarks, one attendee stated that insurance plans in Michigan were withholding the primary care payment increase from physicians. Mann explained that in some states, all of the payment increases were required to be paid through insurance carriers, but said that the physician should ultimately receive the payment.

"If the money isn't flowing, that would be a problem," she said, pledging to follow up on the issue.

Given the rapid changes made to policies at the federal and state level, Mann acknowledged the possibility that a communication gap could exist between physicians and policy officials. She advised physicians that if state officials tell them they cannot be reimbursed for a specific service or cannot be paid at an anticipated rate, they should consult with CMS for verification.

"If you're finding that state officials say they can't reimburse for that, it could be misinformation," said Mann.

Noting that many CMS pilot projects offer bonuses or shared savings for meeting performance measurements as a way of rewarding physician offices for positive patient health outcomes, several physicians pointed out that such improvements can be difficult to achieve if patients do not comply with care recommendations, including taking their medications as needed.

When one attendee asked about the prospect of holding patients accountable for not following a physician's recommendations with the prospect of a financial penalty, Mann said that taking the opposite tack -- such as offering patients some kind of reward to join a gym, obtain a physical exam and/or take their medications appropriately -- is better policy.

"When you charge patients a penalty, that doesn't work with medicine," Mann responded. "If you provide incentives, we'll share the cost of it."